Arnold Eiser | University of Pennsylvania (original) (raw)

Papers by Arnold Eiser

Research paper thumbnail of By-Person Factor Analysis in Clinical Ethical Decision Making: Q Methodology in End-of-Life Care Decisions

American Journal of Bioethics, Aug 1, 2004

To determine the usefulness of Q methodology to locate and describe shared subjective influences ... more To determine the usefulness of Q methodology to locate and describe shared subjective influences on clinical decision making among participant physicians using hypothetical cases containing common ethical issues. Qualitative study using by-person factor analysis of subjective Q sort data matrix. University medical center. Convenience sample of internal medicine attending physicians and house staff (n = 35) at one midwestern academic health sciences center. Presented with four hypothetical cases involving urgent decision making near the end of life, participants selected one of three specific clinical actions offered for each case. Immediately afterward and while considering their decision, each respondent sorted twenty-five subjective self-referent items in terms of the influence of each statement on their decision-making process. By-person factor analysis, where participants are defined as variates, yielded information about the attitudinal background the physicians brought to their consideration of each hypothetical case. We performed a second-order factor analysis on all of the subjective viewpoints to determine if a smaller core of shared attitudes existed across some or all of the four case vignettes. Factor scores for each item and post-sort comments from interviews conducted individually with each respondent guided the interpretation of ethical perspective used by these respondents in making clinical decisions about the cases. Second-order factor analysis on seventeen viewpoints used by physicians in the four hypothetical urgent decision cases revealed three moderately correlated (r2 < 40%) subjective core attitudinal guides used broadly among all the cases and among sixteen of the seventeen original factors. Across all the cases, our participants were guided in general by: (1) patient-focused beneficence, (2) a patient- and surrogate-focused perspective that includes risk avoidance, and (3) best interest of the patient guided by ethical values. Economic impact on the physician, expediency in resolution of the situation, and the expense of medical treatment were not found to be influential determinants in this study. Q sorting and by-person factor analysis are useful qualitative methodological tools to study the complex structure of subjective attitudes that influence physicians in making medical decisions. This study revealed the subjective viewpoints used by our physician participants as they made ethically challenging treatment decisions. The three second-order factors identified here are grounded in current bioethical values as well as the personal traits of physicians. The participants' decision methods appear to resemble casuistry more than principle-based decision making. Generalizability of results will require further studies.

Research paper thumbnail of Contents, Vol. 30, 1982

Research paper thumbnail of The role of angiography in vascular access surgery

Springer eBooks, 1983

Maintenance of reliable access to the circulation continues to be a vexing problem for haemodialy... more Maintenance of reliable access to the circulation continues to be a vexing problem for haemodialysis patients and the medical staff responsible for their care. With the current dialysis population ageing1,2 and the almost universal acceptance of elderly3 and diabetic4 patients for maintenance haemodialysis, preservation of existing access is vital. We found angiography to be a safe technique that is helpful in planning new access procedures and diagnosing problems in established access. This report will review the techniques utilized, list the indications for, and demonstrate representative findings in the angiographic procedures done in our dialysis population over the past 8 years.

Research paper thumbnail of Diabetes and Your Eyes: A Pilot Study on Multimedia Education for Underserved Populations

American Medical Informatics Association Annual Symposium, 2002

Research paper thumbnail of The Current State of Pharma and the FDA: Approval of a Dementia Drug as a Case in Point

The American Journal of Medicine, Dec 1, 2021

Research paper thumbnail of Does over-expression of transforming growth factor-beta account for the increased morbidity in African-Americans?: Possible clinical study and therapeutic implications

Medical Hypotheses, Nov 1, 2010

African-Americans experience an excessive prevalence of a number of apparently disparate disorder... more African-Americans experience an excessive prevalence of a number of apparently disparate disorders that all appear to be, at least in part, mediated by the over-expression or activation of transforming growth factor-beta (TGF-beta) signaling pathways, and that certain genotypes including the codon 10 polymorphism occur more commonly among African-Americans and appears to predispose to these disorders. These disorders, fibrosing in nature, include hypertension, focal glomerulosclerosis, diabetic nephropathy, end stage renal disease, sarcoidosis, uterine leiomyoma, keloids, myocardial fibrosis, and glaucoma. The specific polymorphism for TGF-beta, codon 10, has been implicated in glomerulosclerosis and diabetic nephropathy as well as cardiac transplant rejection. Although TGF-beta over-expression is not the sole factor in these disorders, it is suggested that by designing future clinical studies that consider genomic differences in TGF-beta expression, a more complete understanding of these clinical disorders will be possible. A more thorough understanding of the genetic basis of disease will like promote improved therapeutic regimens and may help reduce the disparate health outcomes for African-Americans as well as improve treatment of individuals of various and diverse ethnic backgrounds.

Research paper thumbnail of Using Rasch measurement to investigate the cross-form equivalence and clinical utility of Spanish and English versions of a diabetes questionnaire: a pilot study

PubMed, 2002

The purpose of this research was to use Rasch measurement to study the psychometric properties of... more The purpose of this research was to use Rasch measurement to study the psychometric properties of data obtained from a newly developed Diabetes Questionnaire designed to measure diabetes knowledge, attitudes, and self-care. Specifically, a methodology using principles of Rasch measurement for investigating the cross-form equivalence of English and Spanish versions of the Diabetes Questionnaire was employed. A total of fifty diabetes patients responded to the questionnaire, with 26 participants completing the English version. Analyses detected problems with the attitude items. We attributed the scaling problems to the use of negatively worded items with participants having generally low educational backgrounds. Analysis of the knowledge and self-care items yielded unidimensional variables with clinically meaningful item hierarchies that may have relevance to treatment protocols. Furthermore, the knowledge and the self-care items from the two versions of the Diabetes Questionnaire met our criteria for establishing cross-form equivalence and thus allow quantitative comparisons of person measures across versions. Limitations of the study and suggested refinements of the Diabetes Questionnaire are discussed.

Research paper thumbnail of The underachieving advance directive: recommendations for increasing advance directive completion

PubMed, 2001

Advance directives have failed to achieve a substantial completion rate nationwide despite prior ... more Advance directives have failed to achieve a substantial completion rate nationwide despite prior efforts. We hypothesize that the continued low completion rate itself inhibits their utility and application. In this commentary we recommend linking the completion of advance directives to the time when health insurance is initiated or renewed by amending the Patient Self Determination Act. This would relocate the time and locus of their completion from the emotional turmoil of hospital admission and acute illness to a more equanimous time when family and others can be consulted and involved. Moreover actuating increased utilization may require non-coercive incentives as well as education. Amending the Patient Self Determination Act to require providing advance directive forms at the initiation of healthcare insurance in conjunction with educational and/or incentives could be more effective than the current arrangements.

Research paper thumbnail of Rationale, principles, and educational approaches of organizational transormation

Journal of General Internal Medicine, 1999

Research paper thumbnail of The assessment of diabetes knowledge and self-efficacy in a diverse population using Rasch measurement

PubMed, 2006

The purpose of this research was to develop survey instruments to evaluate diabetes knowledge and... more The purpose of this research was to develop survey instruments to evaluate diabetes knowledge and self-efficacy in a diverse population, and investigate the psychometric properties of data obtained with these instruments using Rasch measurement. Two-hundred and fifty-five urban-dwelling participants with diabetes were recruited to complete surveys through independent interviews. To evaluate the association of health literacy on metabolic control, formal literacy and hemoglobin A1c fingerstick testing were performed. Rasch analysis of the data yielded item and person calibrations for self-efficacy and knowledge, with variable maps created to provide both norm and criterion-referenced interpretations. Knowledge scale person separation reliability was 0.50 and item separation reliability was 0.98; while self-efficacy scale person separation reliability was 0.72 with item separation reliability of 0.92. Statistically significant partial correlations were observed between knowledge and health literacy (r = 0.41, p<.001), and self-efficacy and hemoglobin A1c (r = -0.33, p<.001). However, there was no correlation between diabetes knowledge and hemoglobin A1c (r = 0.035, p = 0.29), or health literacy and A1c (r = 0.022, p = 0.36). Diabetes knowledge varied, with non-English speaking individuals having lower measures than English speakers (t(252) = -4.86, p<.001). Non-English speaking individuals also had lower self-efficacy measures than English speakers (t(251) = -2.68, p = .008). Current knowledge deficits and perceptions of self-management may be estimated visually through variable mapping, which may help in individualizing informational needs for people with diabetes.

Research paper thumbnail of Environmentally Mediated Health Disparities

The American Journal of Medicine, Jun 1, 2023

Research paper thumbnail of Burnout and the Ethos of Medical Practice

Mayo Clinic Proceedings, Apr 1, 2016

Research paper thumbnail of Warfarin, Calciphylaxis, Atrial Fibrillation, and Patients on Dialysis: Outlier Subsets and Practice Guidelines

The American Journal of Medicine, Apr 1, 2014

Research paper thumbnail of Urban Fitness Centers: Removing Barriers to Promote Exercise in Underserved Communities

Journal of Health Care for the Poor and Underserved, Feb 1, 2010

African Americans, women, the elderly, obese people, and those in underserved communities are les... more African Americans, women, the elderly, obese people, and those in underserved communities are less likely than others to participate in leisure-time physical activity. Mercy Catholic Medical Center opened two fitness centers in low-income, predominately minority Philadelphia neighborhoods. Obese/overweight women from ethnic minorities living in low-income neighborhoods participated most frequently.

Research paper thumbnail of The Effects of Alcohol on Renal Function and Excretion

Alcoholism: Clinical and Experimental Research, Apr 1, 1987

Research paper thumbnail of Integrating Quality Improvement Into Continuing Medical Education Activities Within a Community Hospital System

American Journal of Medical Quality, Sep 13, 2012

The integration of the Mercy Health System&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;am... more The integration of the Mercy Health System&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s quality improvement (QI) and continuing medical educational (CME) activities is described. With the implementation of computerized medical data, the opportunities for QI-focused CME are growing. The authors reviewed their regularly scheduled series and special CME programs to assess their impact on quality care processes. Clinical improvements were affected by combining national guidelines and advancements with local clinical data and interactions with physicians within interdisciplinary as well as specialty conferences. Case-based, multidisciplinary conferences lent themselves to this process to a greater extent than didactic conferences. The latter also could lead to QI when the topics were focused on specific quality initiatives that often are part of a national QI initiative. Although the authors consider these efforts to be at an intermediate stage of development, they have observed several QI/patient safety process improvements.

Research paper thumbnail of Experiential Learning of Systems-Based Practice: A Hands-on Experience for First-Year Medical Residents

Academic Medicine, Oct 1, 2008

This policy monograph highlights some of the major problems with the health care system in the Un... more This policy monograph highlights some of the major problems with the health care system in the United States today and proposes a fundamental change in the way that primary care and principal care are delivered and financed. It recommends voluntary certification and recognition of primary care and specialty medical practices that provide patient-centered care based on the principles of the Chronic Care Model; use evidence-based guidelines; apply appropriate health information technology; and demonstrate the use of "best practices" to consistently and reliably meet the needs of patients while being accountable for the quality and value of care provided. The American College of Physicians (ACP) introduces the term "advanced medical home" to distinguish these practices and calls for consideration and testing of this model of care. The issues identified and positions offered in this monograph address major concerns about the status of the U.S. health care system. The monograph contains the following four policy positions: Position 1. ACP calls for a comprehensive public policy initiative that would fundamentally change the way that primary care and principal care (whether provided by primary care or specialty care physicians) are delivered to patients by linking patients to a personal physician in a practice that qualifies as an advanced medical home. Position 2. Fundamental changes should be made in third party financing, reimbursement, coding, and coverage policies to support practices that qualify as advanced medical homes. Position 3. Fundamental changes should be made in workforce and training policies to assure an adequate supply of physicians who are trained to deliver care consistent with the advanced medical home model, including internists and family physicians. Position 4. Further research on the advanced medical home model and a revised reimbursement system to support practices structured according to this model should be conducted and should include national pilot testing.

Research paper thumbnail of Angiotensin-converting enzyme inhibitors and lithium toxicity

The American Journal of Medicine, Jul 1, 1992

Research paper thumbnail of Withdrawal from dialysis: The role of autonomy and community-based values

American Journal of Kidney Diseases, Mar 1, 1996

• By examining the ethical features of dialysis withdrawal as well as transcultural differences i... more • By examining the ethical features of dialysis withdrawal as well as transcultural differences in attitudes toward withdrawal, one can have a better understanding of the role of autonomy and community-based values on medical decision-making. Three distinctive patterns of withdrawal are described herein. The first concerns patients suffering from an advanced state of physical or mental decline. When a patient or health care surrogate decision maker requests cessation of therapy because it fails to be beneficent for the patient in his or her totality, the physician should be prepared to cooperate, in accord with beneficence and nonmalfeasance as well as autonomy. The second pattern occurs when the patient loses decisional capacity, and the surrogate decision maker makes unreasonable requests for nonbeneficial care. At issue is what constitutes nonmaleficence and beneficence in this setting, the provider and surrogate differing on whether continuing dialysis constitutes beneficence. Such a dilemma can alleviated by community-based consensus guidelines with consent of the patient before losing capacity. The dialysis network is potentially a unit of patient and professional community. In third pattern, the patient's decision to withdraw appears to be inappropriate to their potential for benefit from continued therapy. The nephrologist and patient are conflicted on what constitutes beneficence, with the former holding that continuation is morally superior. In such cases, the physician must mediate the situation in a beneficent fashion not solely dictated by a constraining view of patient autonomy.

Research paper thumbnail of Assessing professionalism: a review of the literature

Medical Teacher, Jun 1, 2004

Although assessing professionalism poses many challenges, gauging and detecting changes in profes... more Although assessing professionalism poses many challenges, gauging and detecting changes in professionalism is impossible without measurement. This paper is a review of techniques used to assess professionalism during the past 20 years. The authors searched five electronic databases and reference lists from 1982 to 2002. Eighty-eight assessments were retained and organized into content area addressed (i.e. ethics, personal characteristics, comprehensive professionalism, diversity) and type of outcome examined (i.e. affective, cognitive, behavioral, environmental). Instead of creating new professionalism assessments, existing assessments should be improved. Also, more studies on the predictive validity of assessments and their use as part of formative evaluation systems are recommended. Based on the review, suggestions are presented for assessing medical students, resident physicians and practicing physicians.

Research paper thumbnail of By-Person Factor Analysis in Clinical Ethical Decision Making: Q Methodology in End-of-Life Care Decisions

American Journal of Bioethics, Aug 1, 2004

To determine the usefulness of Q methodology to locate and describe shared subjective influences ... more To determine the usefulness of Q methodology to locate and describe shared subjective influences on clinical decision making among participant physicians using hypothetical cases containing common ethical issues. Qualitative study using by-person factor analysis of subjective Q sort data matrix. University medical center. Convenience sample of internal medicine attending physicians and house staff (n = 35) at one midwestern academic health sciences center. Presented with four hypothetical cases involving urgent decision making near the end of life, participants selected one of three specific clinical actions offered for each case. Immediately afterward and while considering their decision, each respondent sorted twenty-five subjective self-referent items in terms of the influence of each statement on their decision-making process. By-person factor analysis, where participants are defined as variates, yielded information about the attitudinal background the physicians brought to their consideration of each hypothetical case. We performed a second-order factor analysis on all of the subjective viewpoints to determine if a smaller core of shared attitudes existed across some or all of the four case vignettes. Factor scores for each item and post-sort comments from interviews conducted individually with each respondent guided the interpretation of ethical perspective used by these respondents in making clinical decisions about the cases. Second-order factor analysis on seventeen viewpoints used by physicians in the four hypothetical urgent decision cases revealed three moderately correlated (r2 &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 40%) subjective core attitudinal guides used broadly among all the cases and among sixteen of the seventeen original factors. Across all the cases, our participants were guided in general by: (1) patient-focused beneficence, (2) a patient- and surrogate-focused perspective that includes risk avoidance, and (3) best interest of the patient guided by ethical values. Economic impact on the physician, expediency in resolution of the situation, and the expense of medical treatment were not found to be influential determinants in this study. Q sorting and by-person factor analysis are useful qualitative methodological tools to study the complex structure of subjective attitudes that influence physicians in making medical decisions. This study revealed the subjective viewpoints used by our physician participants as they made ethically challenging treatment decisions. The three second-order factors identified here are grounded in current bioethical values as well as the personal traits of physicians. The participants&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; decision methods appear to resemble casuistry more than principle-based decision making. Generalizability of results will require further studies.

Research paper thumbnail of Contents, Vol. 30, 1982

Research paper thumbnail of The role of angiography in vascular access surgery

Springer eBooks, 1983

Maintenance of reliable access to the circulation continues to be a vexing problem for haemodialy... more Maintenance of reliable access to the circulation continues to be a vexing problem for haemodialysis patients and the medical staff responsible for their care. With the current dialysis population ageing1,2 and the almost universal acceptance of elderly3 and diabetic4 patients for maintenance haemodialysis, preservation of existing access is vital. We found angiography to be a safe technique that is helpful in planning new access procedures and diagnosing problems in established access. This report will review the techniques utilized, list the indications for, and demonstrate representative findings in the angiographic procedures done in our dialysis population over the past 8 years.

Research paper thumbnail of Diabetes and Your Eyes: A Pilot Study on Multimedia Education for Underserved Populations

American Medical Informatics Association Annual Symposium, 2002

Research paper thumbnail of The Current State of Pharma and the FDA: Approval of a Dementia Drug as a Case in Point

The American Journal of Medicine, Dec 1, 2021

Research paper thumbnail of Does over-expression of transforming growth factor-beta account for the increased morbidity in African-Americans?: Possible clinical study and therapeutic implications

Medical Hypotheses, Nov 1, 2010

African-Americans experience an excessive prevalence of a number of apparently disparate disorder... more African-Americans experience an excessive prevalence of a number of apparently disparate disorders that all appear to be, at least in part, mediated by the over-expression or activation of transforming growth factor-beta (TGF-beta) signaling pathways, and that certain genotypes including the codon 10 polymorphism occur more commonly among African-Americans and appears to predispose to these disorders. These disorders, fibrosing in nature, include hypertension, focal glomerulosclerosis, diabetic nephropathy, end stage renal disease, sarcoidosis, uterine leiomyoma, keloids, myocardial fibrosis, and glaucoma. The specific polymorphism for TGF-beta, codon 10, has been implicated in glomerulosclerosis and diabetic nephropathy as well as cardiac transplant rejection. Although TGF-beta over-expression is not the sole factor in these disorders, it is suggested that by designing future clinical studies that consider genomic differences in TGF-beta expression, a more complete understanding of these clinical disorders will be possible. A more thorough understanding of the genetic basis of disease will like promote improved therapeutic regimens and may help reduce the disparate health outcomes for African-Americans as well as improve treatment of individuals of various and diverse ethnic backgrounds.

Research paper thumbnail of Using Rasch measurement to investigate the cross-form equivalence and clinical utility of Spanish and English versions of a diabetes questionnaire: a pilot study

PubMed, 2002

The purpose of this research was to use Rasch measurement to study the psychometric properties of... more The purpose of this research was to use Rasch measurement to study the psychometric properties of data obtained from a newly developed Diabetes Questionnaire designed to measure diabetes knowledge, attitudes, and self-care. Specifically, a methodology using principles of Rasch measurement for investigating the cross-form equivalence of English and Spanish versions of the Diabetes Questionnaire was employed. A total of fifty diabetes patients responded to the questionnaire, with 26 participants completing the English version. Analyses detected problems with the attitude items. We attributed the scaling problems to the use of negatively worded items with participants having generally low educational backgrounds. Analysis of the knowledge and self-care items yielded unidimensional variables with clinically meaningful item hierarchies that may have relevance to treatment protocols. Furthermore, the knowledge and the self-care items from the two versions of the Diabetes Questionnaire met our criteria for establishing cross-form equivalence and thus allow quantitative comparisons of person measures across versions. Limitations of the study and suggested refinements of the Diabetes Questionnaire are discussed.

Research paper thumbnail of The underachieving advance directive: recommendations for increasing advance directive completion

PubMed, 2001

Advance directives have failed to achieve a substantial completion rate nationwide despite prior ... more Advance directives have failed to achieve a substantial completion rate nationwide despite prior efforts. We hypothesize that the continued low completion rate itself inhibits their utility and application. In this commentary we recommend linking the completion of advance directives to the time when health insurance is initiated or renewed by amending the Patient Self Determination Act. This would relocate the time and locus of their completion from the emotional turmoil of hospital admission and acute illness to a more equanimous time when family and others can be consulted and involved. Moreover actuating increased utilization may require non-coercive incentives as well as education. Amending the Patient Self Determination Act to require providing advance directive forms at the initiation of healthcare insurance in conjunction with educational and/or incentives could be more effective than the current arrangements.

Research paper thumbnail of Rationale, principles, and educational approaches of organizational transormation

Journal of General Internal Medicine, 1999

Research paper thumbnail of The assessment of diabetes knowledge and self-efficacy in a diverse population using Rasch measurement

PubMed, 2006

The purpose of this research was to develop survey instruments to evaluate diabetes knowledge and... more The purpose of this research was to develop survey instruments to evaluate diabetes knowledge and self-efficacy in a diverse population, and investigate the psychometric properties of data obtained with these instruments using Rasch measurement. Two-hundred and fifty-five urban-dwelling participants with diabetes were recruited to complete surveys through independent interviews. To evaluate the association of health literacy on metabolic control, formal literacy and hemoglobin A1c fingerstick testing were performed. Rasch analysis of the data yielded item and person calibrations for self-efficacy and knowledge, with variable maps created to provide both norm and criterion-referenced interpretations. Knowledge scale person separation reliability was 0.50 and item separation reliability was 0.98; while self-efficacy scale person separation reliability was 0.72 with item separation reliability of 0.92. Statistically significant partial correlations were observed between knowledge and health literacy (r = 0.41, p<.001), and self-efficacy and hemoglobin A1c (r = -0.33, p<.001). However, there was no correlation between diabetes knowledge and hemoglobin A1c (r = 0.035, p = 0.29), or health literacy and A1c (r = 0.022, p = 0.36). Diabetes knowledge varied, with non-English speaking individuals having lower measures than English speakers (t(252) = -4.86, p<.001). Non-English speaking individuals also had lower self-efficacy measures than English speakers (t(251) = -2.68, p = .008). Current knowledge deficits and perceptions of self-management may be estimated visually through variable mapping, which may help in individualizing informational needs for people with diabetes.

Research paper thumbnail of Environmentally Mediated Health Disparities

The American Journal of Medicine, Jun 1, 2023

Research paper thumbnail of Burnout and the Ethos of Medical Practice

Mayo Clinic Proceedings, Apr 1, 2016

Research paper thumbnail of Warfarin, Calciphylaxis, Atrial Fibrillation, and Patients on Dialysis: Outlier Subsets and Practice Guidelines

The American Journal of Medicine, Apr 1, 2014

Research paper thumbnail of Urban Fitness Centers: Removing Barriers to Promote Exercise in Underserved Communities

Journal of Health Care for the Poor and Underserved, Feb 1, 2010

African Americans, women, the elderly, obese people, and those in underserved communities are les... more African Americans, women, the elderly, obese people, and those in underserved communities are less likely than others to participate in leisure-time physical activity. Mercy Catholic Medical Center opened two fitness centers in low-income, predominately minority Philadelphia neighborhoods. Obese/overweight women from ethnic minorities living in low-income neighborhoods participated most frequently.

Research paper thumbnail of The Effects of Alcohol on Renal Function and Excretion

Alcoholism: Clinical and Experimental Research, Apr 1, 1987

Research paper thumbnail of Integrating Quality Improvement Into Continuing Medical Education Activities Within a Community Hospital System

American Journal of Medical Quality, Sep 13, 2012

The integration of the Mercy Health System&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;am... more The integration of the Mercy Health System&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s quality improvement (QI) and continuing medical educational (CME) activities is described. With the implementation of computerized medical data, the opportunities for QI-focused CME are growing. The authors reviewed their regularly scheduled series and special CME programs to assess their impact on quality care processes. Clinical improvements were affected by combining national guidelines and advancements with local clinical data and interactions with physicians within interdisciplinary as well as specialty conferences. Case-based, multidisciplinary conferences lent themselves to this process to a greater extent than didactic conferences. The latter also could lead to QI when the topics were focused on specific quality initiatives that often are part of a national QI initiative. Although the authors consider these efforts to be at an intermediate stage of development, they have observed several QI/patient safety process improvements.

Research paper thumbnail of Experiential Learning of Systems-Based Practice: A Hands-on Experience for First-Year Medical Residents

Academic Medicine, Oct 1, 2008

This policy monograph highlights some of the major problems with the health care system in the Un... more This policy monograph highlights some of the major problems with the health care system in the United States today and proposes a fundamental change in the way that primary care and principal care are delivered and financed. It recommends voluntary certification and recognition of primary care and specialty medical practices that provide patient-centered care based on the principles of the Chronic Care Model; use evidence-based guidelines; apply appropriate health information technology; and demonstrate the use of "best practices" to consistently and reliably meet the needs of patients while being accountable for the quality and value of care provided. The American College of Physicians (ACP) introduces the term "advanced medical home" to distinguish these practices and calls for consideration and testing of this model of care. The issues identified and positions offered in this monograph address major concerns about the status of the U.S. health care system. The monograph contains the following four policy positions: Position 1. ACP calls for a comprehensive public policy initiative that would fundamentally change the way that primary care and principal care (whether provided by primary care or specialty care physicians) are delivered to patients by linking patients to a personal physician in a practice that qualifies as an advanced medical home. Position 2. Fundamental changes should be made in third party financing, reimbursement, coding, and coverage policies to support practices that qualify as advanced medical homes. Position 3. Fundamental changes should be made in workforce and training policies to assure an adequate supply of physicians who are trained to deliver care consistent with the advanced medical home model, including internists and family physicians. Position 4. Further research on the advanced medical home model and a revised reimbursement system to support practices structured according to this model should be conducted and should include national pilot testing.

Research paper thumbnail of Angiotensin-converting enzyme inhibitors and lithium toxicity

The American Journal of Medicine, Jul 1, 1992

Research paper thumbnail of Withdrawal from dialysis: The role of autonomy and community-based values

American Journal of Kidney Diseases, Mar 1, 1996

• By examining the ethical features of dialysis withdrawal as well as transcultural differences i... more • By examining the ethical features of dialysis withdrawal as well as transcultural differences in attitudes toward withdrawal, one can have a better understanding of the role of autonomy and community-based values on medical decision-making. Three distinctive patterns of withdrawal are described herein. The first concerns patients suffering from an advanced state of physical or mental decline. When a patient or health care surrogate decision maker requests cessation of therapy because it fails to be beneficent for the patient in his or her totality, the physician should be prepared to cooperate, in accord with beneficence and nonmalfeasance as well as autonomy. The second pattern occurs when the patient loses decisional capacity, and the surrogate decision maker makes unreasonable requests for nonbeneficial care. At issue is what constitutes nonmaleficence and beneficence in this setting, the provider and surrogate differing on whether continuing dialysis constitutes beneficence. Such a dilemma can alleviated by community-based consensus guidelines with consent of the patient before losing capacity. The dialysis network is potentially a unit of patient and professional community. In third pattern, the patient's decision to withdraw appears to be inappropriate to their potential for benefit from continued therapy. The nephrologist and patient are conflicted on what constitutes beneficence, with the former holding that continuation is morally superior. In such cases, the physician must mediate the situation in a beneficent fashion not solely dictated by a constraining view of patient autonomy.

Research paper thumbnail of Assessing professionalism: a review of the literature

Medical Teacher, Jun 1, 2004

Although assessing professionalism poses many challenges, gauging and detecting changes in profes... more Although assessing professionalism poses many challenges, gauging and detecting changes in professionalism is impossible without measurement. This paper is a review of techniques used to assess professionalism during the past 20 years. The authors searched five electronic databases and reference lists from 1982 to 2002. Eighty-eight assessments were retained and organized into content area addressed (i.e. ethics, personal characteristics, comprehensive professionalism, diversity) and type of outcome examined (i.e. affective, cognitive, behavioral, environmental). Instead of creating new professionalism assessments, existing assessments should be improved. Also, more studies on the predictive validity of assessments and their use as part of formative evaluation systems are recommended. Based on the review, suggestions are presented for assessing medical students, resident physicians and practicing physicians.